AOCOIAC-4.0-Manual-CMF-Classification
Contents
1. sa He wl 1950 belg S5a2041d s sou ejg uonpajas NpowW Mandible 91 P A0 m BO P right BO Midface 92 10i L0 P10 Oi m Oil P10 L0 10i Z0OIi O right R G W1 i 10i LO P10 0i 0 L0 10i ZOW SY AO Surg ret O left R li W1 li Copy to clipboard Direct access to the AOCMF Surgery Reference portal at a remaining basic level of the classification is provided by selecting the appropriate icon AO Surg Ref on the right of the fracture code 28 11 2013 page 41 43 2 AOCMF 5 Acknowledgements This software project was funded by the AO Foundation AOTrauma and AOCMF through the activities of the AO Classification Supervisory Committee and its Classification Groups and implemented by AO Clinical Investigation and Documentation The Pediatric Classification Group PACG coordinated and supervised the development of this AO COIAC database extension Software core project team Laurent Audig CH AOCID Methodological expertise Dirk Sauter DE Programmer Ing Buro Marschelke Reichenau DE Jim Kellam USA Medical expertise Module long bones for adults Theddy Slongo CH Medical expertise Module long bones for children Peter Cornelius DE Medical expertise CMF Module Julie Agel USA OTA Coding and Classification Committee Craniomaxillofacial Classification Group CMCG Current core group Subgroups Other contributors J Prein CH Ch2. Fragmented Major No bone loss d Bone loss defect 28 11 2013 page 15 43 AOCMF 3 1 1 Condylar Process The Level 3 system for the condylar process region P is described in details by Neff et al 5 Subreqions Fractures of the condylar process P can be specified according to their course within the three subregions Head H Neck N and Base B which are illustrated in the detailed Level 3 view Figure 19 It is possible to specify separate fracture within each of the three subregions Figure 19 Fractured Undetermined H Head N Neck B Base Condylar head 0 Non displaced 1 Displaced 2 Dislocated Ramus stump 0 Non displaced 1 Displaced 0 Orthotopic 1 Dystopic 0 No loss 1 Loss 2 Increase f Access to more detailed view Open The detailed Level 3 view can be accessed also from the bottom link Open within the menu window presented in the Figure 19 above The subregions can be classified as fractured directly from this detailed view by clicking on the respective subregions and selecting fractured on the associated menu window Figure 20 28 11 2013 page 16 43 42 AOCMF Figure 20 Not fractured Fractured Undetermined m Medial to the pole zone p Within or lateral to the pole zone Fragmentation 0 Not fragmented 1 Fragmented minor 2 Fragmented major Vertical apposition 0 Complete 1 Partial 2 Lost Not fractured Fr
3. i Sr da o t s ey WJ Reproduced from Cornelius et al 3 Four transitional zones between adjacent symphysis and body subdivisions 1 anterior transitional zones and between adjacent body and angle ramus subdivisions 2 posterior transitional zones are defined and the rules for classification of fracture location and continuity across subdivisions are applied within AO COIAC 3 1 1 Panoramic view To classify mandibular fractures according to the Level 2 system the panoramic view of the mandible should be selected by clicking on the corresponding view on the left column Figure 3 This view should be presented in the central window for classification Note we recommend to switch the view from color to black and white by clicking on the related icon on the tool bar Show drawings in black white 28 11 2013 page 6 43 AOCMF Figure 5 AO COIAC Program Database Help E Not fractured State Location Midface Skull base Cranial vault Mandible uonpa as ain pol To support the classification process the mouse pointer can be transformed into a pen a by double click within the central window anywhere outside the illustration and vise versa the pen can be used to draw the fracture line s see the main user manual The regions or subregions corresponding to these drawn lines are selected as fractured in accordance with rules and definitions e g lo
4. AO Foundation Executive Editor Marcelo Figari Gregorio S nchez Aniceto General Editor Daniel Buchbinder Su Authors Ricardo Cienfuegos Carl Peter Cornelius Edward Ellis Ill George Kushner AO rgery Reference Mandible back to CMF home gt Decision Surgical approach Treatment Aftercare fF Note Search Q md 0 All Surgical approaches All Treatments mm mm Angle and ramus simple ung a ve Online reference in clinical life Additional material Anatomy Mandibulomaxillary fixation MMF complex Pons 28 11 2013 page 21 43 AOCMF 4 Fractures of the cranium 4 1 General overview 4 1 1 Level 1 system Identification of patients with fractures of the midface skull base and cranial vault can be implemented on the Level 1 system from the skull window interface Figure 26 The respective fractured area is highlighted in blue Figure 26 of Not fractured Not fractured Not fractured Fractured Fractured Fractured Undetermined Undetermined Undetermined 4 1 2 Level 2 system The Level 2 system allows specifying the fracture location within predefined regions It is presented and explained in details in the corresponding tutorials for the midface 6 and skull base cranial vault 7 To classify fractures of the cranium according to the Level 2 system the skull must be selected by clicking on any appropriate view on the top row exc
5. respectively Those diagnosed with bone loss d are marked with additional stripes Superimposed to the color scheme of fragmentation The orbital walls can be specified as Linear frature Fx Lamellar Fx or Defect Fx which are highlighted in yellow orange and red respectively after classification 28 11 2013 page 34 43 42 AOCMF While a linear fracture can be further specified as non displaced or displaced a lamellar fracture and a defect fracture are always classified as displaced The three subregions of the apex can be specified as non displaced or displaced The ZSS and ZFS subregions can be specified as fractured as shown in Figure 41 Figure 41 v Linear Fx Lamellar Fx Defect Fx v 0 Non displaced v 0 Non displaced 1 Displaced 1 Displaced Linear Fx Lamellar Fx v EET 0 Not fragmented Undetermined vi 1 Fragmented Morphology 7 0 Non displaced 0 Non displaced 1 Displaced vv 1 Displaced No bone loss d Bone loss defect Fractured Undetermined Fractured Undetermined Undetermined 28 11 2013 page 35 43 2 AOCMF 4 1 Fractures of the skull base 93 The defined regions for the skull base are described in details by di leva et al 7 and illustrated in Figure 42 considering the endocranial a and exocranial b surfaces Figure 42 A Anterior skull base Ca Central anterior M Middle Cm Central middle P Posterior Cp Central pos
6. the only exception is for the zygoma en bloc fracture pattern as described in section 4 2 2 28 11 2013 page 39 43 2 AOCMF Figure 46 Fractured Undetermined Not fragmented Fragmented Non displaced Displaced but not depressed Depressed No bone loss d Bone loss defect Undetermined 0 Not fragmented 1 Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed No bone loss d Bone loss defect 28 11 2013 Fractured Undetermined 0 Not fragmented 1 Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed No bone loss d Bone loss defect 5 Superior rim m Medial rim left side Anterior wall fractured Opacification Access to more detailed view O Occipital left Fractured Undetermined 0 Not fragmented l Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed No bone loss d Bone loss defect page 40 43 AOCMF 4 3 Fracture code and Surgery Reference After completion of the classification the fracture code is presented within the bottom right screen window Figure 47 The codes can be copied to the computer clipboard following double click of the mouse over them Figure 47 me H F CMTR 92 107 CMTR Appendix Case Collection 01 01 2012 01 04 2012 Bj r BARK IFM ato 2 aN State Location 7 Midface Skull base Cranial vault lv I Mandible
7. 1 Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed No bone loss d Bone loss defect Fractured 28 11 2013 page 38 43 AOCMF 4 2 Fractures of the cranial vault 94 The defined regions for the cranial vault are described in details by Di leva et al 7 and illustrated in Figure 45 Figure 45 a F Frontal bone T Temporal bone P Parietal bone O Occipital bone S Sphenoid bone skull base Regions labelled in red are from the skull base Reproduced from di leva et al 7 The classification menu windows specific to the cranial vault are presented in Figure 46 Each of the 4 regions F P T and O can be classified according to fragmentation in 2 classes not fragmented highlighted in yellow fragmented highlighted in orange and displacement in 3 classes non displaced displaced but not depressed depressed In addition bone loss d defect can be specified and highlighted with stripes over the color scheme Involving the frontal bone the superior and part of the medial orbital rims can be selected as being fractured their detailed classification can be further performed from the detailed view that can be accessible directly from within the menu window of the frontal bone click on Open just below Access to more detail view see Figure 41 Note The classification of subregions within the detailed view is not initiated by fracture classification within the region
8. Le Fort I and Il 28 11 2013 page 29 43 AOCMF 4 2 1 Fracture morphology Fracture morphology is specified by Level 3 parameters that are described in the tutorial papers by Cornelius et al midface 8 and by Kunz et al orbits 9 respectively Central midface and Zygoma Fractures in the LCM ICM UCM and Zygoma regions can be described according to three parameters Fragmentation 0 Not fragmented 1 Fragmented Displacement 0 Not displaced 1 Displaced Bone loss d bone loss defect Regions with non fragmented and fragmented fracture are coloured in yellow and orange respectively Figure 35 Those diagnosed with bone loss d are marked with additional stripes superimposed to the color scheme of fragmentation as illustrated for the mandible Figure 18 Fracture displacement is not represented graphically however although recorded in the AO COIAC database when documenting patients 35 savy nen fractured T Fractured Undetermined Fracture pattern 8 attern os Fort I 0 Not fragmented 1 Fragmented vel o Non displaced 1 Displaced vi No bone loss d Bone loss 4 Bone loss defe O O C i Inferior rim Access to more Access to more detailed view view Open 28 11 2013 Not fractured vi Fractured Undetermined Fracture pattern Le Fort I EE EN 0 Not fragmented 1 Fragmented 0 Non displaced 1 Displaced v vw No bone l
9. classification menu windows specific to the central midface regions LCM ICM and UCM are presented in Figure 31 and to the zygoma pterygoid process and palate regions in Figure 32 Figure 31 Fractured Fractured Undetermined Undetermined Fracture pattern Le Fort I NOE Le Fort I Fight side Le Fort M Le Fort I Le Fort M 0 Not fragmented Lef side 1 Fragmented Le Fort I Mace 9 Le Fort II 1 Displaced ER 0 Not fragmented d Bone loss defect l Fragmented 0 Non displaced No or mild atrophy l Displaced Moderate atrophy No bone loss Severe atrophy d Bone loss defect m Medial rim right side Fractured Undetermined Fracture pattern Le Fort I Morphology 0 Not fragmented m Medial rim left side 1 Fragmented 0 Non displaced 1 Displaced No bone loss d Bone loss defect Orbital rim i Inferior rim Access to more detailed view 28 11 2013 page 26 43 AOCMF Figure 32 Z 7ygoma left Pt Pterygoid process right Fractured Fractured Undetermined Fracture pattern Le Fort I st Se Le Fort I Zygoma en bloc Le Fort I Morphology gt 0 Not fragmented Undetermined Fracture pattern Le Fot M 0 No vertical separation 1 Fragmented l Vertical separation from maxilla LCM ICM en P Paate 2 1 Displaced Fractured No bone loss Undetermined d Bone loss defect _ Morphology gt Orbital rim l One transverse fracture line Lateral rim 2 One para or m
10. double click on the respective tooth root The fractured alveolar bone is highlighted in violet Figure 11 Figure 11 Fractured Undetermined Not fractured Fractured Undetermined When an alveolar process fracture involves several contiguous teeth each involved tooth root should be classified similarly It is more convenient to use the side table on the right side of the AO COIAC window This can be achieved by checking the box in front of the respective tooth numbers Figure 12 Figure 12 Alveolar process ma E Alveolar process 48 a El Alveolar process 47 E Alveolar process 46 Alveolar process 45 Alveolar process 44 F Alveolar process 43 E Alveolar process 42 E Alveolar process 41 El Alveolar process 31 28 11 2013 page 11 43 2 AOCMF Fractured regions Regions potentially involved by the fracture scenario that are difficult to analyze or un evaluable e g due to lack or shortages in diagnostic imaging can be indicated as undetermined These regions are marked with a grid pattern Figure 13 Figure 13 Fractured Undetermined Confined Not confined Not fractured Fractured Undetermined Confined Not confined The Level 2 classification involves specifying the fractured regions This is achieved by selecting Fractured on the respective menu windows By clicking outside these windows they will close and the involved region
11. 10 11 2 il Proces EEE EE NR 16 3 1 Fracture code illustrations and Surgery Reference rrrarrrnnrrnnnrrrarennnrrvnnrnnnnennn 20 A Fractures ofthe anMuvv eavvaavav4 vvirevcvd4ervvvmmmemmv nevn 22 4 1 GE EEE EEE 22 4 1 1 Level 1 EE wiincnsavnacncasiesincnna sens tnaaiedndaaatnar daar ete cnanteaetanietecnantvaelanieteiaaatnentns 22 Ae EN SV Sle EEE EE EE S 22 EE ES SE EEE 23 42 Fractures ofthe NIE 92 varmvsvvea4vvrmikseenerksaemeinlasnmenssrinlasnen 25 4 2 1 Classification menu Windows ararnnnennnrrnnnrnnnnennnrnnnnennnnennrnnnnennnrnnnennnnennsen 26 4 2 1 Dentition and atrophy rrrarennnnrvanrvrnnrvnnnnranrnrnnrrnnrnrnnennnnnnnrrnnanennnsnnanennnsennnen 27 4 2 1 Alveolar process fractures cccccccsecceceseeeseeeneeeneeeeeeeseeeneeeseeeseeeseeeneeeneeenes 27 22 Fre PN secre ORAA EAEE aaa Aae aiaa aie 29 4 2 1 Fracture morphology vvs ken 30 41 Fractures of the skull Dase 93 vasre 36 4 1 1 Endocranial surface ccccccceccsecceeeseeeneeeneeeneeeseeeseeseeeseeeseeeseeeneeeneeeseeenes 36 4 1 1 Exocranial SUrfaCe rrarrnnnrnnnrnnnnnnnrnnnrnnernnnrnnernnnrnnernnernnernnrnnrnnernnnrnnennnnnnnn 38 4 2 Fractures of the cranial vault 94 rernnnnnnnornnnnnnnrnrnnennnnnnnnrrnnnennnrnnnnennnnennsrnnnnennn 39 4 3 Fracture code and Surgery Reference rrnnnnrnnnnannnnnrnnnnrnvnnnrnnnnrnvnnnnnnnnennnnnnnnnnen 41 Dx PACINO WICC OTIS EE EEE 42 JO 2 EE 43 28 11 2013 page 2 43 A
12. 2 AOCMF On the top left corner of the windows interface the skull is presented for Level 1 classification on the left column and top row respectively illustrations of the mandible and cranium give access to Level 2 and Level 3 classifications By mouse click on the desired illustrative view a corresponding larger illustration is presented in the central window with delimitations of Level 2 regions or Level 3 subregions depending on the selected view On the top row a panoramic illustration of the zygomas orbits and nose delimits Level 3 subregions for the cranium Similarly on the left column an illustration of both condylar processes is used for Level 3 classification of condylar process subregions head neck and base Fracture classification may be implemented directly on the selected illustrations or using the side table on the right side of the screen window 3 Mandibular fractures 91 3 1 Level 1 system Identification of patients with mandibular fractures can be implemented on the Level 1 system from the skull window interface Figure 3 The mandible is highlighted in blue and the code 91 is shown on the bottom right window Figure 3 91 Mandible Facture Undetermined Level 1 28 11 2013 page 5 43 2 AOCMF 3 1 Level 2 system The defined regions for the mandible are described in details by Cornelius et al 3 and illustrated in Figure 4 Figure 4 Maar on ee
13. 42 AOCMF AO COIAC COmprehensive Injury Automatic Classifier software for the classification and documentation of injuries User Manual Version 4 0 0 Craniomaxillofacial Fracture Classification Module Audige L Cornelius P C Kunz C Buitrago Tellez C Prein J AOCID Stettbachstrasse 6 8600 Dubendorf Switzerland Email aocoiac aofoundation org Internet www aofoundation org aocoiac November 28 2013 4 AO Foundation AO COIAC Version 4 0 CE We F k LI i AO COmprehensive Injury Automatic Classifier Software for the classification and documentation of injuries TA 3 ETA 2000 2013 by AO Foundation This program i proieded by U S and international copyright laws 28 11 2013 page 1 43 AD AOCMF Table of contents te MOON 3 Bs OME CSSA ION MO ddo serrr nn E EE E 3 3 Mandibular fractures 91 rrrnnnnnnnrnnnnennnnnnanrnnnnnvnnrnnnnernnnrnnrnnnnennnrennnrnnnnennnennnsennnnennsene 5 Bele Levert System upiera aair an ERa EE A Eaa Ipa a 5 Sele LP Syste simn EEE 6 G OG PG Panoramic VICW EE 6 G 6 DERU EEE EAE E E 8 JE Mandibular ON 10 3 1 3 Fracture location tates teea sane Sates tance ieee stave taten Oualceicen sane balan tea iaasane laa tuaeiviatanelveada cians 11 3 1 Level 3 System rrrrennrennnennronnnennnennnvnnnennnnnnnsnnnennnnnnnsnnnsnnnennnennnennnnnnnnnnnnnnennne 13 3 1 1 Angle Ramus Body Symphysis ParasymphysisS rrrrnrrvnnnrrrnnrrvrnnrennnrrennnr 14 gt Go 1
14. D AOCMF 1 Introduction The AO Foundation developed the software named AO COIAC AO COmprehensive Injury Automatic Classifier to facilitate the diagnosis coding and documentation of injuries This software version includes the long bone fracture classification adult and paediatric as well as the new AOCMF fracture classification modules The AOCMF Classification Group developed a hierarchical 3 level craniomaxillofacial fracture classification system 1 The fundamental Level 1 distinguishes 4 major anatomical units including the mandible code 91 midface 92 skull base 93 and cranial vault 94 Level 2 relates to the location of the fractures within defined topographical regions within each units Level 3 relates to fracture morphology in these regions regarding fragmentation displacement and bone defects as well as the involvement of specific anatomical structures An introduction to the CMF classification module in AO COIAC has been presented 2 This manual highlights in more details its functionality The general features of the AO COIAC software for classification and documentation are presented in a separate main manual Important note this manual do not present and explain the CMF classification system in details The user should read the related tutorials published in a special issue of the Journal of Cranio maxillofacial Trauma and Reconstruction CMTR Reference to the specific tutorials will be made within appropriat
15. ace Mandible uonpajas ajnpow om P NK XEN at QQls Injured Absent before trauma Tooth loss trauma related Undetermined Crown and or root fracture Tooth loosening E Tooth 45 Tooth 44 Tooth 43 Tooth 42 Tooth 41 Tooth 31 Tooth 32 Tooth 33 E Tooth 34 Tooth 35 Tooth 36 Tooth 37 E Tooth 38 Injured Absent before trauma Tooth loss trauma related Undetermined Crown and or root fracture Alveolar process ma F Alveolar process 18 28 11 2013 page 9 43 2 AOCMF 3 1 2 Mandibular atrophy The level of mandibular atrophy can be specified separately for the Body B and Symphysis Parasymphisis S regions as soon as one tooth is absent before trauma in the concerned region With no teeth missing the classification dialogue window Figure 7 for mandibular atrophy remains inactive According to the level of atrophy specified part of the concerned region is masked in white for illustration Figure 10 v No atrophy Mild atrophy Moderate atrophy Severe atrophy No atrophy v Mild atrophy No atrophy Mild atrophy w Moderate atrophy Mild atrophy Moderate atrophy Moderate atrophy Severe atrophy Severe atrophy 28 11 2013 page 10 43 2 AOCMF 3 1 3 Fracture location Alveolar fractures Alveolar fractures can be specified from the menu window accessible by
16. actured Undetermined 0 Not fragmented 1 Fragmented minor 2 Fragmented major 0 Non displaced 1 Contact reduced 2 Contact lost 0 No angulation 1 More than 5 to 45 2 More than 45 0 No shortening 1 Shortening Not fractured Fractured Undetermined 0 Not fragmented 1 Fragmented minor 2 Fragmented major 0 Non displaced 1 Contact reduced 2 Contact lost 0 No angulation 1 More than 57 to 45 2 More than 45 0 No shortening 1 Shortening Fractures of the Condylar Head H can be further classified according to the location of the fracture line s medial to the pole zone m or within or lateral to it p Figure 21 When only the location of a fracture is specified and not its fragmentation the involved subregions are highlighted in blue Figure 21 Not fractured Fractured Undetermined m Medial to the pole zone p Within or lateral to the pole zone Not fractured Fractured Undetermined m Medial to the pole zone p Within or lateral to the pole zone 28 11 2013 page 17 43 42 AOCMF Fragmentation For each subregion the level of fragmentation is specified in one of three categories as for the other A B and S regions however using specific category definitions The relevant tutorial paper should be consulted for more details 5 The same color scheme is used to represent the gradation of fragmentation Figure 22 e Yellow not fragmente
17. airman Anterior Skull Base M Ehrenfeld DE P Cornelius DE B Kellman USA J Hirsch SE L Audig CH K Shumrick USA A Sugar UK C Kunz CH C Matula AU B Alpert USA J Frodel USA A di leva AU B Strong USA R Rudderman USA Condylar Process Ch Lindavist FI C Buitrago Tellez CH M Rasse AU P Louis USA A Neff DE P Cornelius DE The software programming is implemented by D Sauter H Marschelke a MARSCHELKE Ingenieurb ro Marschelke EEE Strandbadstrasse 6 MESSTECHNIK 78479 Reichenau Germany AO COIAC is supported by The Orthopedic Trauma Association OTA Classification Database and Outcome Committee 28 11 2013 page 42 43 AD AOCMF 6 References 1 Audig L Cornelius CP Di leva A Prein J CMF Classification Group Introduction to the first AO classification system for fractures of the craniomaxillofaxial skeleton rationale methodological background developmental process and objectives Craniomaxillofacial Trauma amp Reconstruction 2014 in press Audig L Cornelius CP Buitrago Tellez CH Kunz C Neff A Di leva A Ruddermann R Frodel J Prein J AO classification system for fractures of the craniomaxillofaxial skeleton software solution for documentation Craniomaxillofacial Trauma amp Reconstruction 2014 in press Cornelius CP Audig L Kunz C Ruddermann R Buitrago T llez CH Frodel J Prein J AO classification system for fractures of the craniomaxillofaxial skel
18. ards displacement of neck and Base fractures Angulation of neck and Base fractures This classification is however not performed using the menu windows but via the entry table on the right side of the screen window after selecting the Level 3 tab Figure 23 Figure 23 El Mandible right PETE J EGG Ondylar neck l Te 6 jee Undetermined Fragment O 0 Not fragmented Location 2 H Head O 1 Fragmented minor N Neck 2 Fragmented major E Base Sidewards 1 0 Non displaced Disol cond O 0 Non displaced F pl cond 5 O 2 Contact lost J 1 Displaced O 2 Dislocated Direction O sn one Direction 5 aa C Lateral one C Lateral Cl Anterior Ej ane O None T Posterior one C Posterior Angulation O 0 No angulation Displ ramus O 0 Non displaced 1 Displaced 1 More than 57 to 457 2 More than 45 Direction L Medial Direction None None L Lateral fy C Lateral Anterior Anterior C None J O None C Posterior r C Posterior Dist cond head z ol ae Override z 0 No shortening Leystopic 1 Shortening Ramus height 0 No loss i 1 Loss 2 Increase 28 11 2013 page 19 43 AOCMF 3 1 Fracture code illustrations and Surgery Reference After completion of the classification the fracture code is presented within the bottom right screen window Figure 24 The codes can be copied to the computer clipboard followin
19. ation of Level 3 subregions 3 1 1 Dentition The dentition status can be specified from the menu windows that can be opened by double mouse click on the respective tooth or teeth The classification categories are illustrated in Figure 8 along with their graphical presentation on the panoramic view The tooth status can be set as undetermined as shown for tooth 42 When a series of teeth needs to be specified as absent before trauma to document partial or full edentualism it is more convenient to use the side table on the right side of the AO COIAC window This can be achieved by checking the box in front of the respective tooth numbers Figure 9 28 11 2013 page 8 43 42 AOCMF Figure 8 Figure 9 Tooth 48 0 Injured Absent before trauma Tooth loss trauma related Undetermined Crown and or root fracture Tooth loosening Tooth 45 0 2 Injured Absent before trauma Tooth loss trauma related Undetermined Crown and or root fracture Tooth loosening Injured Absent before trauma Tooth loss trauma related Undetermined Crown and or root fracture Tooth loosening Tooth 47 00 Injured Absent before trauma Tooth loss trauma related Undetermined Crown and or root fracture Tooth loosening Tooth 44 000 Injured Absent before trauma Tooth loss trauma related Undetermined Crown and or root fracture You are in training mode saving any data is not possible 9 Cranio midf
20. cation inside the transition zones of the mandible Figure 6 Figure 6 dd Tonn 28 11 2013 page 7 43 AOCMF A double click with the mouse pointer on a region or subregion of interest opens up menu windows tabulating respective Level 2 and Level 3 descriptors to specify the fracture in greater detail Figure 7 Figure 7 _P Condylar process right B Body right Fractured Fractured Fractured Undetermined Undetermined Location Confined H Head Confined Not confined i N Neck SS Mot co nfined Undetermined Morphology Displacement with regard to the fossa FE Condvlar head l Fragmented Minor 0 Non displaced 2 Fragmented Major l Fragmented Minor 0 Not fragmented 1 Dis P laced Mo b one loss 2 F rag ME nted Majo r eter d Bone loss defect Wo bane loss Ramus stump o bone h 0 Non displaced d Bone loss defect 1 Displaced Distorsion of condylarhead TEER 0 Orthotopic Mild atrophy 1 Dystopic Change of ramus height Moderate atrophy 0 No loss Severe atrophy 1 Loss Access to more detailed view Fractured Open Undetermined Confined Not confined Fractured Undetermined Important note When selecting one or more Level 2 regions as fractured all other regions or subregions that are not explicitly categorized as fractured are considered as not fractured by default The same principle applies to the classific
21. d e Orange minor fragmentation e Red major fragmentation Figure 22 Fragmentation 0 Not fragmented 1 Fragmented minor 2 Fragmented major Fragmentation 0 Not fragmented l Fragmented minor 2 Fragmented major Fragmentation 0 Not fragmented l Fragmented minor 2 Fragmented major Displacement Displacement parameters are related to Injuries the Condylar Process P as a whole or Fractures within the specific subregions In the first situation their documentation is done using the menu window from the panoramic view Figure 19 they include The position of the condylar head with regard to the fossa The position of the ramus stump with regard to the fossa Distortion of the condylar head Change of the ramus height 28 11 2013 page 18 43 2 AOCMF In the second situation their documentation is done using the respective menu window of the subregions from the detailed view Figure 20 they include Head o Loss of vertical apposition Neck and Base o Sidewards displacement o Angulation o Override Shortening The direction of displacement for condylar process fractures can also be specified according to two parameters related to antero posterior and medio lateral direction for each of the following displacement parameters Position of the condylar head with regard to the fossa Position of the ramus stump with regard to the fossa Sidew
22. e sections of this manual The use of AOCOIAC for CMF fracture classification should be referenced as follows Audig L Cornelius P C Kunz C Buitrago Tellez C Prein J 2013 AO COIAC COmprehensive Injury Automatic Classifier Software User Manual Version 4 0 0 Craniomaxillofacial Fracture Classification Module AO Foundation Davos Switzerland 43 pages or Audig L Cornelius P C Kunz C Buitrago Tellez C Neff A Di leva A Rudderman R Frodel J Prein J 2014 AO classification system for fractures of the craniomaxillofaxial skeleton software solution for documentation Craniomaxillofacial Trauma and Reconstruction in press 2 CMF classification module The CMF classification module can be accessed by double click on the cranium of the adult skeleton either using the training tab no classification data will be saved Figure 1 or using the fracture tab for case documentation after registering patient demographics and trauma event It is organized and presented to facilitate fracture coding according to any of the 3 levels of the classification Figure 2 28 11 2013 page 3 43 2 AOCMF Figure 1 da AO COAC Program Database Help You are in training mode saving any data is not possible z o a wn 2 f Training You are in training mode saving any data is not possible 9 Cranio midface Mandible Oo SISK FP at E uonpajas ajnpow ls 28 11 2013 page 4 43 4
23. ept the detailed view of the orbits zygoma and nose on its right hand side The selected view should be presented in the central window for classification e g the frontal view in Figure 27 28 11 2013 page 22 43 2 AOCMF Figure 27 Program Database Help v Training You are in training mode saving any data is not possible 9 Cranio midface Mandible mo Cu HR X F Auto a afk AO Classification 9 Cranio midface Mandible E Not fractured Level 1 Level 2 Level3 Dentition Level 3 focused State Location iv ra Midface uonpajas ajnpow Skull base Cranial vault Mandible The classification process is similar to that presented for the mandible By double click on any delimited bone region a specific dialogue widow is presented for classification including Level 2 as well as some Level 3 parameters e g for the Zygoma in Figure 28 4 1 3 Level 3 system The Level 3 system allows classifying fractures according to relevant morphological characteristics Level 3 parameters pertinent to the involved region s are presented for Classification within the menu windows mentioned above Figure 28 Other Level 3 parameters are related to subregions delimited within the detailed view of the zygomas orbits and nose that is accessed by double click on the right hand side icon on the top row Figu
24. eton Level 2 mandible fractures Craniomaxillofacial Trauma amp Reconstruction 2014 in press Cornelius CP Audig L Kunz C Ruddermann R Buitrago T llez CH Prein J AO classification system for fractures of the craniomaxillofaxial skeleton Level 3 mandible fractures Craniomaxillofacial Trauma amp Reconstruction 2014 in press Neff A Audig L Rasse M Kolk A Dalla Torre D Cornelius CP AO classification system for fractures of the craniomaxillofaxial skeleton Level 3 condylar process fractures Craniomaxillofacial Trauma amp Reconstruction 2014 in press Kunz C Cornelius CP Prein J Buitrago Tellez CH Frodel J Ruddermann R Audig L AO classification system for fractures of the craniomaxillofaxial skeleton Level 2 midface fractures Craniomaxillofacial Trauma amp Reconstruction 2014 in press Di leva A Audig L Kellman RM Shumrick KA Ringl H Matula C AO classification system for fractures of the craniomaxillofaxial skeleton Level 3 skull base and cranial vault fracture Craniomaxillofacial Trauma amp Reconstruction 2014 in press Cornelius CP Audig L Kunz C Ruddermann R Buitrago Tellez CH Frodel J Prein J AO classification system for fractures of the craniomaxillofaxial skeleton Level 3 midface fractures Craniomaxillofacial Trauma amp Reconstruction 2014 in press Kunz C Cornelius CP Audig L Ruddermann R Buitrago T llez CH Prein J AO classification system for fractures of the crani
25. g double click of the mouse over them Figure 24 zoo JA EE KK NG s ee 42 AOCMF You are in training mode saving any data is not possible 9 Cranio midface Mandible oo RINK 2 at QER F Z u u 4 E Not fractured State Location Posterior skull base Occipital Cranial vault right Frontal bone Ea uonpajas ajNpoW Boag Temporal bone Parietal bone Occipital Cranial vault left Frontal bone Temporal bone Parietal bone Occipital Mandible right 3 Condylar process Coronoid Booga Angle Ramus SOG08 a JNM Mandible 91 P BO m P right NO 24 AO Surg Ref Copy to clipboard The related illustrations can be copied or saved electronically for use in publications and 50 gt 50 7 Save Image Copy to clipboard presentations using the icon bar Direct access to the AOCMF Surgery Reference portal Figure 25 at a remaining basic level of the classification is provided by selecting the icon AO Surg Ref on the right of the fracture code Figure 24 28 11 2013 page 20 43 AOCMF Figure 25 um Program Database Help Training AO Surgery Reference Online mem 2 AO Foundation Browse the AO Foundation web portal to obtain further information about the specified classification code 5 0 A Home Contact Disclaimer Sitemap W 8 amp Member login
26. id sagittal fracture line i Inferior rim 3 Two or more fracture lines Access to more detailed view No bone loss d Bone loss defect The classification menu windows specific to the orbit regions orbital walls and apex are presented in Figure 33 At the bottom of all menu windows except that of the Lower Central Midface LCM and Pterygoid process an option allows accessing directly the detailed panoramic view of subregions Figure 29 by clicking on Open 4 2 1 Dentition and atrophy The dentition status at the lower central midface can be specified similarly to that of the mandible The user should refer to that section 3 1 1 for more details A level of atrophy can be recorded in one of three categories see LCM in Figure 31 when at least one tooth is set as absent before trauma see section 3 1 2 4 2 1 Alveolar process fractures Alveolar process fractures can be documented at the lower central midface similarly to those in the mandible see section 3 1 3 28 11 2013 page 27 43 2 AOCMF Figure 33 Fractured Fractured Undetermined Undetermined Fracture pattern Displacement Le Fort III 0 Non displaced 1 Displaced Zygoma en bloc rare Le 0 Non displaced se _ Ol Orbital lateral wall left Involved structures Fractured Inferior orbital fissure Undetermined Internal orbital buttress anterior orbit Fracture pattern Internal orbital buttress mid orbit Le Fort I Palatine bone orb
27. ied as fragmented highlighted in orange or not fragmented highlighted in yellow displaced or not displaced as well as with bone loss d defect Figure 38 The lower nasal septum belongs to the LCM the anterior antral wall and the highlighted part of the area of zygomatico maxillary crest belong to the ICM Figure 38 Fractured Undetermined Morphology 0 Not fragmented 1 Fragmented 0 Non displaced 1 Displaced No bone loss d Bone loss defect Fractured Undetermined Fractured Fractured Undetermined Undetermined Fractured Undetermined 28 11 2013 page 32 43 2 AOCMF Subregions of the Zygoma include an area of the zygomatico maxillary crest the zygomatic body both being involved in the Zygoma en bloc pattern as well as the zygomatic arch and its temporal origin Figure 39 Zygomatic arch can have single highlighted in yellow or multiple highlighted in orange fractures and the fracture s can be further described as displaced or not Other subregions of the zygoma are presented in the following section along with other subregions of the orbits Figure 39 Not fractured Fractured Undetermined Single Fx Multiple Fx Undetermined 0 Non displaced 1 Displaced v Fractured a Undetermined Undetermined Fracture pattern Fracture pattern Zygoma en bloc Zygoma en bloc Orbit As presented in the classification menu windows in Figure 33 fractures within orb
28. ital regions walls and apex can be described as being displaced or not Displacement is not illustrated on the graphical display In addition specific orbital structures can be selected as involved or not If a fracture pattern is selected Le Fort III NOE or Zygoma en bloc the displacement parameter can be specified however this attribute then concerns the whole pattern and not just the concerned region Figure 40 In addition no structures can be selected within the regions involved in the fracture pattern 28 11 2013 page 33 43 AOCMF Figure 40 OI Orbital lateral wall right Fractured Fractured Undetermined Undetermined racture pat Fracture patterr Le Fort I Le Fort Il Zygoma en bloc Zygoma en bloc Displacement 0 Non displaced 0 Non displaced 1 Displaced 1 Displaced Involved structures Inferior orbital fissure Inferior orbital fissure Greater wing of sphenoid Greater wing of sphenoid i Access to more detailed view Access to more detailed view Open The detailed panoramic view of the subregions of the midface offers a mapping of the subregions for more refined classification Figure 41 Orbital rims can be described similarly to the midface regions LCM ICM UCM and Zygoma Figure 35 according to fragmentation Not fragmented Fragmented displacement Not displaced Displaced and bone loss defect Regions with non fragmented and fragmented fracture are coloured in yellow and orange
29. ital surface depressed Zygoma en bloc Ev 0 Non displaced 1 Displaced Involved structures Inferior orbital fissure Greater wing of sphenoid Fractured 0 Non displaced Undetermined 0 Non displaced 1 Displaced ratio ayes b eral sel Involved structures Internal orbital buttress mid orbit Superior orbital fissure Nasolacrimal duct lacrimal bone Medial Canthal ligament insertion Optic canal Access to more detailed view 28 11 2013 page 28 43 AOCMF 4 2 2 Fracture patterns Fracture patterns are part of the Level 2 system of the midface Three fracture patterns can be specified from the menu windows depending on the involved regions Le Fort LF type I Il and Ill Zygoma en bloc ZEB Naso orbito ethmoidal NOE While the NOE pattern is central both Le Fort and ZEB patterns can be specified separately on either or both sides On any side the Le Fort I II and Ill patterns are exclusive i e they cannot be combined The NOE pattern can be combined with ZEB and or Le Fort I patterns The ZEB pattern can be combined with Le Fort II or Le Fort I with or without NOE patterns The regions involved in any specified pattern or associated patterns are highlighted in purple such as bilateral Le Fort patterns Figure 34 NOE and Zygoma en bloc patterns are also illustrated within the detailed panoramic view Figure 34 Le Fort N f LJ kat LAN NOE and Zygoma en bloc
30. lar process 41 Epogen np nA npn Alveolar process 31 Alveolar process 32 3 1 1 Angle Ramus Body Symphysis Parasymphysis The Level 3 system for the mandible regions A B and S is described in details by Cornelius et al 4 Fragmentation Fractured A B and S regions can be classified according to the level of fragmentation in 3 classes The definition of these classes is the same for B and S regions however differ for A regions The user should consult the relevant tutorial to find these definitions A color scheme is used to represent the gradation of fragmentation Figure 17 e Yellow not fragmented e Orange minor fragmentation e Red major fragmentation 28 11 2013 page 14 43 2 AOCMF Figure 17 0 Not fragmented 1 Fragmented Minor 2 Fragmented Major No bone loss d Bone loss defect Not fragmented 0 1 2 Fragmented Major Fragmented Minor No bone loss d Bone loss defect 0 Not fragmented l Fragmented Minor 2 Fragmented Major No bone loss d Bone loss defect Bone loss Bone loss can be specified using the diagnose windows just below the fragmentation Regions identified with bone loss d defect are marked with additional stripes superimposed to the color scheme of fragmentation Figure 18 Figure 18 0 Not fragmented 2 1 Fragmented Minor
31. omaxillofaxial skeleton Level 3 orbital fractures Craniomaxillofacial Trauma amp Reconstruction 2014 in press 28 11 2013 page 43 43
32. oss d Bone loss defect Kg i eee ero rim page 30 43 AOCMF The regions ICM UCM and Zygoma include part of the orbital rims that can be selected within the respective classification menu windows when fractured The affected rims are darkened when selected Figure 35 ICM i inferior rim UCM m medial rim left right Zygoma I inferior rim and lateral rim The Pterygoid process can be classified as being separated vertically from the maxilla orange colour or not yellow colour as the only Level 3 classification parameter Figure 32 and Figure 36 Figure 36 0 No vertical separation l Vertical separation from maxilla LEM ICM 0 No vertical separation 1 Vertical separation from maxilla LCM ICM A fractured palate can be further described with regard to the course of the fracture line s as well the occurrence of bone loss Figure 37 Figure 37 Not fractured Fractured Undetermined 1 One transverse fracture line 2 One para or mid sagittal fracture line 3 Two or more fracture lines No bone loss d Bone loss defect 28 11 2013 page 31 43 AOCMF The detailed panoramic view of the subregions of the midface offers a mapping of the subregions for more refined classification Subregions of the UCM include the medial orbital rims presented in a subsequent section and the nasal bone and the upper nasal septum Fractures of the nasal bone can be specif
33. ral views is used Figure 16 This view is accessible by clicking on its smaller format on the left column red arrow There is no Level 3 item for the Coronoid C Note the classification process may be restricted to the Level 1 or Level 2 not taking the features of fracture morphology within Level 3 into account If Level 3 is applied it is reasonable that all affected regions are classified uniformly at this level to comply with a clear and concise layout Marking of a Level 3 descriptor such as the fragmentation grade in a region or subregion however will automatically retroactivate the Level 1 and Level 2 classification and can be used as a shortcut and timesaver in the coding process 28 11 2013 page 13 43 2 AOCMF Figure 16 Gi Program Database Help pe AO CMF lon Training You are in training mode saving any data is not possible 9 Cranio midface Mandible Cu KJE XM auto am AO Classification 9 Cranio midface Mandible Not fractured State Location E Alveolar process 21 Alveolar process 22 uonpajas ajnpow Alveolar process 23 Alveolar process 24 Alveolar process 25 Alveolar process 26 Alveolar process 27 Alveolar process 28 __ Alveolar process ma Alveolar process 48 Alveolar process 47 Alveolar process 46 P Alveolar process 45 s Alveolar process 44 P Alveolar process 43 Alveolar process 42 Alveo
34. re 29 in color scheme 28 11 2013 page 23 43 42 AOCMF Figure 28 AO COIAC Program Database Help You are in training mode saving any data is not possible 9 Cranio midface Mandible om BIN X FH Auto RQls uonpajas ainpow Zygoma en bloc 0 Not fragmented 1 Fragmented 0 Non displaced 1 Displaced No bone loss d Bone loss defect i Inferior rim Access to more detailed view You are in training mode saving any data is not possible 9 Cranio midface Mandible Ha BA FH ato RA State Location Zygoma right Zygomatic arch Zygomatic arch Zygomatic body Area of Zygom Zygoma left Zygomatic arch Zygomatic arch Zygomatic body Area of Zygom Area of Zygom Anterior antral Interm centra Area of Zygom Anterior antral uoDajas a npoly 28 11 2013 page 24 43 42 AOCMF 4 2 Fractures of the midface 92 The defined regions for the midface are described in details by Kunz et al 6 and illustrated in Figure 30 Figure 30 a Pterygoid process SD i epe UCM Upper Central Midface Nasal skeleton including bone and nasofrontal maxilla ICM Intermediate Central Midface Parapiriform maxilla and infraorbital maxilla LCM Lower Central Midface Maxillary bodies including infrazygomatic maxilla Z Zygoma zygomatic arch Reproduced from Kunz et al 6 28 11 2013 page 25 43 42 AOCMF 4 2 1 Classification menu windows The
35. s will be highlighter in blue Figure 14 To reverse this selection either use the undo icon available on the icon bar lel or select Not fractured within the menu window that is opened following a new double click on the concerned region Figure 14 i amp F B Body right Q Undetermined Confined Not confined Not fractured Fractured Undetermined Confined Not confined 28 11 2013 page 12 43 2 AOCMF Fractures of the Angle Ramus A Body B and Symphysis Parasymphysis S can be located within their respective region they are described as confined or extent to their adjoining region they are the described as not confined This classification is implemented within the respective Level 2 menu windows Note Condylar Process P and Coronoid C regions are not concerned in this specification If one of the three regions A B and S is coded with a not confined fracture one of its adjoining regions must be coded similarly Figure 15 Figure 15 Not fractured Not fractured i Fractured Fractured Undetermined 7 Undetermined Confined Confined Not confined Not confined 3 1 Level 3 system The Level 3 system is used to specify items related to fracture morphology They are available for coding using the menu windows Figure 7 In addition for fractures of the Condylar Process P a new illustration presenting the two processes in postero anterior and late
36. terior S Sphenoid bone T Temporal bone O Occipital bone P Parietal bone cranial vault Reproduced from di leva et al 7 4 1 1 Endocranial surface The classification menu windows specific to the endocranial surface of the skull base are presented in Figure 43 Each of the 9 regions can be classified according to fragmentation in 2 classes not fragmented highlighted in yellow fragmented highlighted in orange and displacement in 3 classes non displaced displaced but not depressed depressed In addition specific structures can be selected as involved fractured or opacification within the central anterior skull base ethmoid sinus on both sides cribriform frontal sinus and central middle skull base sphenoid sinus 28 11 2013 page 36 43 2 AOCMF Figure 43 Fractured Undetermined _ Morphology 0 Not fragmented l Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed eee Fractured Undetermined _ Morphology iy o Not fragmented 1 Fragmented v 0 Non displaced 1 Displaced but not depressed 2 Depressed Fractured Undetermined 0 Not fragmented 1 Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed Fractured Undetermined 0 Not fragmented l Fragmented 0 Non displaced l Displaced but not depressed 2 Depressed Fractured Opacification Fractured Opacification Fractured Posterior wall fract
37. ured Opacification Fractured Undetermined 0 Not fragmented 1 Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed Fractured Opacification Fractured me Undetermined lt lt lt lt 28 11 2013 0 Not fragmented l Fragmented 0 Non displaced 1 Displaced but not depressed 2 Depressed page 37 43 AOCMF 4 1 1 Exocranial surface The classification menu windows specific to the exocranial surface of the skull base are presented in Figure 44 Each of the 6 regions S T and O can be classified according to fragmentation in 2 classes not fragmented highlighted in yellow fragmented highlighted in orange and displacement in 3 classes non displaced displaced but not depressed depressed similarly to the endocranial surface In addition bone loss d defect can be specified Glenoid fossa fractures can be noted as involving the sphenoid and or the temporal bone and fractures of the occipital condyles are noted within the occipital region Figure 44 Fractured Fractured Undetermined Undetermined 0 Not fragmented 0 Not fragmented 1 Fragmented 1 Fragmented 0 Non displaced 0 Non displaced 1 Displaced but not depressed 1 Displaced but not depressed 2 Depressed 2 Depressed No bone loss No bone loss d Bone loss defect d Bone loss defect Glenoid fossa Fractured Fractured Fractured Undetermined Morphology 0 Not fragmented
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AOCOIAC 4.0 Manual CMF Classification aocmf level 3 classification